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Percutaneous dilatation tracheostomy has become a common procedure for bedside insertion of tracheostomy tubes in the intensive care unit. Management of the airway during the procedure using the laryngeal mask airway (LMA) and other methods has been described. The intubating laryngeal mask airway has several potential benefits for airway management during percutaneous dilatation tracheostomy compared with the LMA. These include the use of both the fibreoptic bronchoscope and tracheal tube if necessary. We report the results of a pilot study of 10 patients that illustrates these advantages.

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SummaryThree adults are described who developed life-threatening hypotension following intravenous codeine phosphate. It is recommended that codeine phosphate should not be given intravenously to adults. Key wordsAnalgesics; codeine phosphate. Complications; hypotension.Codeine phosphate has retained a place in the treatment of moderate pain, despite the availability of new, highly potent synthetic opioids with minimal unpredictable adverse effects. In addition it is a popular analgesic for neurosurgical patients because of its relative lack of sedation and interference with pupillary size. The parenteral preparation of codeine phosphate currently available bears a label listing the intravenous route of administration as an alternative to intramuscular injection. Adverse reactions to intravenous codeine phosphate have been described in children, in whom its use is not recommended [ l]. We describe three adults who developed severe hypotension following intravenous codeine phosphate. Case histories Case IA 17-year-old male, weighing 51 kg, was scheduled for six dental extractions, as a day case. He had previously been investigated for short stature but no cause had been found. He had received two uneventful anaesthetics for squint correction and tonsillectomy some years before.He was prescribed no premedication. Anaesthesia was induced with alfentanil, thiopentone and suxamethonium, and following tracheal intubation was allowed to breathe spontaneously an oxygen/nitrous oxide/enflurane mixture. The patient remained stable throughout surgery, and at the end of the procedure his systolic blood pressure was 120 mmHg, which was identical to the pre-induction value. Codeine phosphate injection 50 mg (McCarthy 60 mg.ml-I) was then given, undiluted, intravenously as a bolus. Almost immediately the patient became pulseless and grey, but the electrocardiograph (ECG) continued to show sinus rhythm at a rate of 90 beat.min-l. The patient's lungs were ventilated with 100% oxygen and external cardiac massage started. Adrenaline (I mg) was given intravenously. After 60 s the pulse became palpable and systolic blood pressure was measured at 40mmHg. The patient remained in sinus rhythm at a rate of 90beat.min-'. Ephedrine 15 mg and atropine 0.6 mg were administered intravenously and 4 min later the systolic blood pressure was 70mmHg, but a further 5 min elapsed before the systolic blood pressure reached 100 mmHg (Fig. 1). At no time did any bronchospasm or rash develop, and there was no increase in body temperature. The patient's trachea was extubated and he was admitted for observation overnight. He remained stable and his ECG was normal. He was discharged the next day, fully recovered, with written instructions that he was allergic to codeine phosphate injection. Case 2A previously fit, 16-year-old female was scheduled for myringoplasty. She was premedicated with lorazepam. Anaesthesia was induced with thiopentone and vecuronium and maintained with enflurane in nitrous oxide and oxygen